Preventive Exercise and Physical Activity

Reducing your Risk of Heart Disease Webinar Series

Created with an educational grant from:

Part 4May 16, 2019

Presenters• Andrea Baer, MS, BCPA – Director of Patient Advocacy and Program Management,

Mended Hearts and Mended Little Hearts. Andrea is also a mom to a 10 year old son with Congenital Heart Disease.

• Albert Lopez D.O. FASPC - Chief Medical Officer of Real Life Health, a personalized cardiovascular- metabolic prevention program. CEO of Lopez internal Medicine Associates, a private practice in Jacksonville, Florida for over 20 years, that focuses on the treatment of lipids, cardiovascular disease, and diabetes. Dr. Lopez is also faculty at Lake Erie College of Osteopathic Medicine - Bradenton Florida campus.

• Tiffany Hackett-Stuart, RN, MHA – Tiffany Hackett-Stuart RN, BS, MHA was born with coarctation of the aorta and bicuspid aortic valve. She became active in advocating for patients after becoming a nurse in 2006. Tiffany works as a nurse case manager at Phoenix Children’s Hospital in Phoenix, Arizona and is passionate about her ability to advocate for her patients.

About Mended Hearts

• Mended Hearts is the largest peer-to-peer support network in the world.

• Mended Hearts mission is:

“To inspire hope and improve the quality of life of heart patients and their families through on-going peer-to-peer support, education, and advocacy”.

• 285 Chapters across the country serving over 460 hospitals.

About the ASPC

• The American Society for Preventive Cardiology mission statement is:

“To promote the prevention of cardiovascular disease, advocate for the preservation of cardiovascular health, and disseminate high-quality, evidence-based information through the education of healthcare clinicians and their patients”.

Exercise as Primary and Secondary Preventionof Cardiovascular Disease

Al Lopez D.O. FASPC

• CMO at Real Life Health – a personalized cardiovascular metabolic prevention program

• CEO of Lopez Internal Medicine Associates

• Lake Erie College of Osteopathic Medicine, Bradenton Campus, - Faculty

Divorce your chair

• Sedentary lifestyle is one of the major risk factors for cardiovascular disease.

• Over 25% of the general population’s attributable risk for MI is due to inactivity.

• Sedentary lifestyle is an important risk factor for chronic disease.

• Cardiovascular disease is pandemic worldwide.

This Photo by Unknown Author is licensed under CC BY-NC

Modifiable Risk Factors

• World Health Organization (WHO) estimates that over 75% of premature CVD is preventable, and improvement of risk factors can prevent disease.

• These modifications include: • Exercise• Diet – 7-10 servings of fruits and vegetables per day, high fiber, low sugar and

salt• Smoking cessation• Weight reduction to ideal body weight (BMI 18.5-24.9)• Alcohol limitation- 1-2 daily for men, 1 per day for women• Lipid lowering therapy• Anti-platelet therapy• Blood glucose control/ normalization - fasting below 95• Blood pressure control • Controlling inflammation

Move it, shake it and groove it!

• Regular exercise and physical activity are important in reversing, reducing symptoms, events or death in a number of chronic illnesses.

• Diabetes, elevated blood sugars, obesity, lipid disorders, high blood pressure, aging, cancer, osteoporosis, depression all improve with regular exercise.

• Cardiovascular disease – heart attack, stroke, arrythmias, peripheral arterial disease, in multiple studies in multiple disciplines, consistently document lower incidence of coronary events in those who are physically active and fit.

Old or New Ideas?

• Sushruta 6th century BC a physician in India, is credited as the first to write a prescription for exercise.

• Herodicus in 5th century BC, a Greek teacher of Hippocrates, prescribed exercise for recovery for illnesses.

• Plato criticized Herodicus on how his training practices were unnecessarily prolonging his lifespan and those of others.

An Exercise Glossary

• Physical activity—bodily movement produced by skeletal muscles that results in energy expenditure beyond the resting level

• Exercise—activity that is planned, structured, repetitive, and purposeful in the sense that improvement or maintenance of physical fitness is the objective

• Physical fitness—includes cardiorespiratory fitness, muscle strength, body composition, and flexibility

• Dose—the energy expended in physical activity

• Intensity—the rate of energy expenditure during such activity

• Absolute intensity—the rate of energy expenditure during exercise, usually expressed in metabolic equivalents (METs)

• MET— metabolic equivalent = 3.5ml of O2 per kg/min; about the energy expended when sitting quietly (8 METs is 8x your resting rate)

• Relative intensity—the percent of aerobic power utilized during exercise expressed as a percent of the maximal heart rate or percent of maximum oxygen consumption (VO2max)

• Fletcher G, Trejo J, Why and How to prescribe exercise: Overcoming the barriers. Cleveland Clinic Journal of Medicine. 2005 August;72(8):645-649, 653-654, 656

Another Exercise Glossary

• Primary prevention – prevention of disease in a patient without known disease

• Secondary prevention – prevention of recurrence of disease

• CVD – cardiovascular disease

• CAD – coronary artery disease

• PVD – peripheral vascular disease

• VO2max – maximum rate of oxygen measured during incremental exercise.

• Relative intensity - percent of aerobic power used during exercise expressed as a percent of maximal heart rate or maximum oxygen consumption.

Main benefits of regular exercise on blood vessels, autonomic balance, and cardiac preconditioning.

Exercise benefits in cardiovascular disease: beyond attenuation of traditional risk factors•C. Fiuza-Luces1,2 na1, A. Santos-Lozano3,4 na1, M. Joyner5, Nature Reviews Cardiologyvolume 15, pages731–743 (2018)

Regular physical activity reduces your chance of having a heart attack, stroke, kidney problems and problems with your blood vessels. For heart disease the risk can be reduced by over 40% (Woodcock et al., 2011)

St James Women’s take Heart Project; Martha Gulati MD et al. -2003

5721 asymptomatic women followed for 8 years; Average age of 52

Highest risks patients were smokers, diabetics and those with lack of exercise.

Exercise was the strongest independent predictor of all cause death

For each unit or MET increase in exercise capacity there was a 12% reduction in mortality

The data confirmed the protective role of higher exercise capacity even in presence of established coronary risk factors

Compared to the highest exercise capacity (>8MET), 5-8 METS doubled risk of death, lowest capacity- <5MET death rate tripled

better treadmill time / greater exercise capacity = less cardiovascular death, overall death, CV disease, or symptoms

Combined resistance training and aerobic exercise benefits

Resistance training along with aerobic training conferred a better effect on lipoprotein profiles in healthy individuals than aerobic activity alone.

1-3 times or < 60 min weekly of resistance exercise, independent of meeting aerobic exercise total goals, reduced risk of total CVD events

Resistance training had no significant risk reduction for CVD if done for more than 60 min or 4 times weekly

Patients with peripheral arterial disease showed Improvement with high intensity resistance training (3 sets of 8 repetitions of exercise for 7 different muscle groups)

Interplay between muscle strength, muscle mass, and CVD

INTERHEART STUDY

• A case-control study of acute myocardial infarction in 52 countries, representing every inhabited continent. 15,152 cases and 14,820 controls were enrolled.

• The relation of the following to myocardial infarction was reported:• smoking• hypertension• diabetes• waist/hip ratio• dietary patterns• physical activity• consumption of alcohol• blood apolipoproteins (Apo) • psychosocial factors

Lancet 2004: 364: 937 - 952

19

INTERHEART

Lancet 2004: 364: 937 - 95220

• Citing: National Lipid Association, Kavita S. Sharma M.D.

Primary Prevention of Cardiovascular Disease

• 30 minutes of moderate intensity exercise 5 days a week or vigorous intensity 20 minutes 3 times a week, or preferably a combination-(moderate 5 days vigorous 2 days per week)

• 10,000 – 15,000 steps daily minimum

• The above is in addition to light activity performed during daily life

• This can be performed in multiple 10 minute bouts throughout the day

• Twice a week doing activities that include major muscle groups that maintain or increase muscular strength and endurance (resistance training)

Primary Prevention of Cardiovascular Disease

• Exceeding the minimum recommended amount of physical activity provides additional benefit

• European Society of Cardiology recommends increasing to 300 minutes weekly of moderate intensity or 150 minutes weekly of vigorous aerobic activity

• Doses above 100 minutes per day of moderate intensity physical activity does not appear to be associated with additional reduction in cardiovascular death, and may in-fact be detrimental

Primary Prevention of Cardiovascular Disease

• Starting with a low intensity activity in sedentary individuals or those with cardiovascular risk factors

• Consider obtaining an exercise prescription with your Doctor or exercise physiologist.

• Reduce excessive sitting to less than 3 hours per day and excessive television to less than 3 hours a day (move 3 minutes per 30-60 minutes)

There is an inverse dose – response between physical activity and all cause mortality, CVD mortality and risk of CAD.

Secondary Prevention of CVD with Exercise

• Assessment of risk should be done as part of a cardiac rehab program and or a stress test

• Individualized exercise recommendations are recommended

• Studies noted on middle aged men and women a 30% reduction of death with aerobic exercise of at least a 3 month duration

• Aerobic exercise in low risk individuals has been shown to be effective as stenting in improving daily functionality, cardiovascular blood flow, is associated with fewer events and death

Secondary Prevention of CVD with Exercise

• 30-60 minute of moderate intensity aerobic activity, such as brisk walking daily, supplemented by an increase in daily lifestyle activities. (e.g. walking during breaks, gardening, and household work)

• Resistance training twice weekly

The ideal exercise program?

• Exercise should consist of a warm up period, endurance training, flexibility exercise, strength or resistance training and a cool down

• If time constraints only allow 30 minutes a day do resistance training 2-3 days and the rest aerobic exercise.

• Warm up is low intensity for 5-10 minutes reducing injury or cardiac event risk. Cool down should last a few minutes

Endurance Training

• This includes brisk walking, running, swimming, cycling, stair stepping elliptical, rowing, cross country skiing.

• These activities involve dynamic exercise – contracting and relaxing of large muscle groups

• Ideally 3-6 times per week for a minimum of 30 minutes per session at a minimum intensity of 40-60% of VO2max or 4-6 METS –this is moderate intensity, up to 85 -90% VO2max or over 8 METS on those who have progressed to this level

• Intensity should be determined by age or physical ability.

• Perceived exertion scale of 12-16 is suggested for healthy adults (Borg scale –goes from 10-20)

Adapted from Drs Fletcher and Trejo at Mayo clinic Jacksonville Florida

Flexibility

• Focus on improving your range of motion

• Stretching improves blood flow and reduced injuries

Lower back and posterior thigh stretches and important to reduce lower back pain

Resistance training

• Repeated movements against low to moderate resistance is an important part of a comprehensive exercise regimen for healthy adults and for those with cardiovascular disease that have been properly screened.

• Improvement has been noted with 8-10 different exercises that utilize major muscle groups 2-3 days per week.

• A balance of strength and endurance is achieved with 8-12 repetitions in healthy adults and 10-15 for cardiac patients, or those 60 or older.

• Give me 40! Men who can do 40 push ups have 96% reduced risk of heart attack, stroke and heart disease vs. men who did less than 10. (a marker of general fitness?)

Adapted from Drs Fletcher and Trejo at Mayo clinic Jacksonville Florida

Last Thoughts

• “Just like medication, the right form of physical activity has to be specialized for each patient.”- Gerald Fletcher MD

• Inactivity has an elevated cardiovascular risk; along with smoking, bad diet, high lipids, inflammation, high blood pressure, obesity, or high blood sugars

• Cardiovascular disease prevention with exercise, along with other forms of risk reduction, reduce premature disability, and death while prolonging survival and quality of life

• Exercise’ positive effect is seen immediately, but its effects are transient. Individuals need to exercise regularly

• Risk, symptom and mortality reduction is noted with even small doses of exercise and peak at about 50-60 minutes of vigorous exercise daily

Where are you on the scale?

A Patient Perspective on ExerciseTiffany Hackett-Stuart, RN, MHAPatient with Congenital Heart Disease

Exercise is beneficial to help with preventing

heart disease and after

diagnosis or event

Mental HealthExercise is not only beneficial to physical health but can also help with anxiety and depression, common conditions for those with heart disease

Even low levels of activity can help reduce the risk of additional heart events

This Photo by Unknown Author is licensed under CC BY

Build it into your day!

Exercise doesn’t have to be a complicated thing, gardening, cleaning the house or walking the dog count as exercise

Be consistent with exercise

Always consult your

Physician

Next Webinar in the Series:

June 6, 2019

12:00 PM ET

Controlling Risk Factors for Women

Thank you to our Sponsor:

www.mendedhearts.org

1-888-HEART-99

www.aspconline.org